Surgical ventricular reconstruction for heart failure.

Congestive heart failure is one of the leading causes of death and complications in the developed world, and coronary artery disease is the major cause of heart failure. Efforts to improve ventricular function, symptoms, and clinical outcomes in patients with heart failure have included neurohormonal inhibition with angiotensin-converting–enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, and aldosterone antagonists, as well as cardiac resynchronization therapy. All these therapies have been shown in randomized clinical trials to be beneficial.1 However, none of them specifically address the coronary disease responsible for ischemic cardiomyopathy and myocardial infarction. Coronary-artery bypass grafting (CABG), which was first used to ameliorate symptoms, is now used to improve survival in selected patients with ischemic heart disease, although the improved outcome of percutaneous coronary intervention (PCI) has resulted in a reduction in the number of CABG procedures that are performed.2-4 CABG remains the standard of care for patients with disease involving at least three vessels or the left main coronary artery.5 Revascularization with CABG can improve the perfusion of viable myocardium but does not restore function in areas of infarction. The large, aneurysmal myocardial segments that were seen in the past in patients with myocardial infarction are seldom seen in the current era of coronary reperfusion. However, regional zones of myocardial dysfunction are still frequently observed. These areas of regional dysfunction may result in adverse cardiac remodeling and the progression of heart failure.6 A surgical procedure to reconstruct dysfunctional myocardial segments and favorably remodel the ventricle, known as surgical ventricular reconstruction, has been developed and is performed in selected patients, usually in conjunction with CABG7,8 (Fig. 1). Previously reported clinical studies of surgical ventricular reconstruction were not randomized and were conducted either in a single center or in multiple centers as observational studies.9-11 In this issue of the Journal, Jones et al.12 report the results of the Hypothesis 2 substudy of the Surgical Treatment for Ischemic Heart Failure (STICH) trial (ClinicalTrials.gov number, NCT00023595). This substudy compared CABG alone with the combined procedure of CABG with surgical ventricular reconstruction. Patients were required to have coronary disease amenable to CABG, a left ventricular ejection fraction of 35% or less, and a dominant anterior region of myocardial akinesia or dyskinesia that was amenable to treatment with surgical ventricular reconstruction. All patients received standard medical and device therapy for heart failure. The results of the Hypothesis 1 substudy of the STICH trial, which compared medical therapy plus CABG with medical therapy alone, are not reported. In the Hypothesis 2 substudy, 1000 patients were recruited from 96 medical centers in 23 countries. The patients in the two study groups were closely matched in terms of demographic characteristics, coexisting illnesses, the proportion who were receiving specific heart-failure medications, the Canadian Cardiovascular Society (CCS) angina class, the New York Heart Association (NYHA) heart-failure class, coronary anatomy, and the extent of anterior myocardial akinesia or dyskinesia. Although Jones et al. indicate that the use of evidence-based medical therapy (including heart-failure medications, pacemakers, and cardioverter–defibrillators) was monitored throughout